Provider Demographics
NPI:1780022582
Name:MOREIRA VIDAL, LORENNA LOURHANCE (MD)
Entity Type:Individual
Prefix:
First Name:LORENNA
Middle Name:LOURHANCE
Last Name:MOREIRA VIDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORENNA
Other - Middle Name:
Other - Last Name:VIDAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:800 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6130
Mailing Address - Country:US
Mailing Address - Phone:215-829-3201
Mailing Address - Fax:215-829-5697
Practice Address - Street 1:800 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-3201
Practice Address - Fax:215-829-5697
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD838612085N0700X, 2085R0202X
PAMD4699662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC092582405Medicaid
MD583205500Medicaid